In his 2020 Presidential Address for the American Society of Clinical Oncology, âEquity: Every patient. Everyday. Everywhere, âLori J. Pierce, MD, challenges medical oncology to imagine a future where fairness is seen as a humanistic standard of oncology practice.
In his 2020 Presidential Address for the American Society of Clinical Oncology, âEquity: Every patient. Everyday. Everywhere, âLori J. Pierce, MD, challenges medical oncology to imagine a future where fairness is seen as a humanistic standard of oncology practice.1
Winning that future will require a fundamental shift from passive observation of disparities to active promotion of equity through behavior change, social justice and action.2 One area to begin this transformation is to ensure that the next generation of medical oncologists values ââand promotes fairness in practice.
The Accreditation Council for Higher Medical Education (ACGME) made cultural competence (CC) a requirement in medical education in 2003, with specifics and standardizations emerging from 2010 to 2020.3.4 An important step forward, ACGME CC focuses primarily on securing therapeutic relationships with patients from diverse backgrounds by avoiding personal grievances and breaches. The programs also provide education on the social determinants of health and cancer disparities. However, many of these discussions do not address how to overcome barriers and provide equitable care.
Most importantly, the way training programs prioritize educational goals and experiences communicates what is vital and what is not. The resulting sense of medical values, the âhidden curriculumâ, is particularly influential in establishing professional identity.5.6 If the hidden curriculum contradicts the formal curriculum, instruction can become counterproductive and even increase trainee burnout.6.7
From my own teaching and learning experiences in 5 training institutions and 8 hospital systems, many programs struggle with equity in their hidden agendas, which inevitably undermines CC efforts, social determinants of health and other parts of formal programs. Hidden curriculum cannot be fixed by simply adding or removing elements, but most programs could dramatically improve their commitment to equity in education by:
- recruit and promote career growth for historically under-represented interns and faculty beyond assignment to leadership roles in diversity, equity and inclusion;
- promote trainee engagement with various mentors and educators;
- promote learning collaborations between university, hybrid and community programs;
- develop interprofessional training with case managers and social workers.
- provide educational opportunities that showcase talents among under-represented interns;
- discuss how historically ineligible or excluded patients can receive the best standards of care;
- develop longitudinal equity skills with corresponding programs.8
Equity requires community buy-in
Black and Latin people represent 13.4% and 18.1% of the US population, respectively, but each group represents only 4% of participants in oncology drug trials.9 Education proportional to demographics – equality – would be a huge achievement. To meet the definition of fairness, trial enrollment must be sufficient to support hypotheses relevant to these populations. The increase in funding opportunities for equity-focused oncology research is promising and useful, but if equity is to become an integral part of oncology research, trainees must learn to integrate equity into any project. of research.
To ensure that leading research institutions do not simply obtain grants to conduct external research on underserved communities, research plans should include a commitment to community-based surveillance and capacity building in partnership with underserved institutions. Certain questions have helped me shape my own commitment to equity in community engagement research, quality improvement, educational research, and clinical trial research in academia and community settings (Table).
Advocacy in clinical practice
Perhaps the most difficult issue to face is inequity in daily practice. Whether intentional or not, we must recognize that our current system of medical oncology creates and continues to perpetuate existing disparities in cancer care. Acknowledging this truth is not to assign the blame, but to understand that fairness in medical oncology will not happen without a change in practice.
Trainees can start by comparing the demographics of their clinic and facility to the community and reflect on how their daily practice patterns are contributing or alleviating health disparities. While some demographics are seldom encountered, programs should offer internships at other institutions so that interns can understand what is happening to groups that their institution does not see regularly. Programs should also promote a culture of active accountability and management of issues of financial toxicity and unsustainable growth in cancer care costs.11-13
Trainee groups should meet with their institution’s medical director and chief physician to learn more about the rationale behind organizational policies that translate into current practice models.
While not all interns will become experts in advocacy or health policy, our training should ensure that all interns understand how organizational, local, state, and federal policies affect a patient’s ability to access cancer care. safe, affordable and efficient. Interns can identify an issue relevant to their intended career goal and present that issue on their state or national âDay on the Hillâ. Interns can also meet with cancer survivors from communities of historically disenfranchised peoples to understand the very different care experiences these groups receive and learn to become an ally and advocate for these patients.
Personal and professional dynamics
The last step in realizing real equity in practice is to ensure that equity is not compartmentalized at work but becomes an instrumental value of life. For people in historic positions of power, this means empowering minority voices in your daily life, actively listening, letting others lead and lead primarily through supportive roles where success is defined by advancing the cause. rather than personal ambitions or distinctions. It also means committing to self-improvement as a person in addition to learning rules for how to interact with people from different cultures, accept feedback, be aware of explicit and implicit biases, blind spots and recognize that good intentions are not synonymous with good deeds. .14
Making equity an inherent value in medical oncology will require a global commitment to change. Training is a natural time when values ââand behaviors are shaped and influence long term practice. Ongoing conversations about advancing the cause of equity are essential if we are to meet the challenge of providing quality cancer care to every patient, every day, everywhere.
- Pierce, LJ. 2021 Presidential Speech: Fairness: Every Patient. everyday. all over. ASCO connections. June 7, 2021. Accessed August 12, 2021. https://connection.asco.org/magazine/features/2021-presidential-address-equity-every-patient-every-day-everywhere
- Braveman P. What are health disparities and health equity? We need to be clear. Public health representative. 2014; 129 (suppl 2): ââ5-8. doi: 10.1177 / 00333549141291S203
- Ambrose AJ, Lin SY, Chun MB. Cultural competency training requirements in higher medical education. J Grad Med Educ. 2013; 5 (2): 227-231. doi: 10.4300 / JGME-D-12-00085.1
- Smith WR, Betancourt JR, Wynia MK, et al. Recommendations for teaching racial and ethnic disparities in health and health care. Ann Med Intern. 2007; 147 (9): 654-665. doi: 10.7326 / 0003-4819-147-9-200711060-00010
- Lawrence C, Mhlaba T, Stewart KA, Moletsane R, Gaede B, Moshabela M. The hidden curricula of medical education: a review of the scope. Acad Med. 2018; 93 (4): 648-656. doi: 10.1097 / ACM.0000000000002004
- Mulder H, Ter Braak E, Chen HC, Ten Cate O. Addressing the Hidden Agenda in the Clinical Workplace: A Practical Tool for Trainees and Faculty. Med Teach. 2019; 41 (1): 36-43. doi: 10.1080 / 0142159X.2018.1436760
- Webster F, Rice K, Dainty KN, Zwarenstein M, Durant S, Kuper A. Failure to Cope: The Hidden Curriculum of Emergency Department Wait Times and the Implications for Clinical Education. Acad Med. 2015; 90 (1): 56-62. doi: 10.1097 / ACM.0000000000000499
- Massachusetts Medical Society. Racial Disparities in Clinical Medicine: Conversations, Perspectives, and Research on Advancing Medical Equity. NEJM Group. https://www.nanosweb.org/fi les / Committees / DEI% 20Resources / NEJM_Group_Racial_Disparities_in_Clinical_Medicine.pdf
- Nazha B, Mishra M, Pentz R, Owonikoko TK. Enrollment of racial minorities in clinical trials: an old problem takes on new urgency in the age of immunotherapy. Am Soc Clin Oncol Educ Book. 2019; 39: 3-10. doi: 10.1200 / EDBK_100021
- McDavitt B, Bogart LM, Mutchler MG et al. Dissemination as dialogue: building trust and sharing research results through community engagement. Previous Dis chronic. 2016; 13: E38. doi: 10.5888 / pcd13.150473
- by Souza JA, Yap BJ, Wroblewski K, et al. Measuring financial toxicity as a clinically relevant outcome reported by patients: validation of the global financial toxicity score (COST). Cancer. 2017; 123 (3): 476-484. doi: 10.1002 / cncr.30369
- Desai A, Gyawali B. Financial Toxicity of Cancer Treatment: Shifting the Discussion from Recognizing the Problem to Identifying Solutions. EClinicalMedicine. 2020; 20: 100269. doi: 10.1016 / j.eclinm.2020.100269
- Mariotto AB, Enewold L, Zhao J, Zeruto CA, Yabroff KR. Medical care costs associated with cancer survival in the United States. Cancer epidemiologic biomarkers Previous. 2020; 29 (7): 1304-1312. doi: 10.1158 / 1055-9965.EPI-19-1534
- Greene-Moton E, Minkler M. Cultural competence or cultural humility? Go beyond the debate. Health promotion practice. 2020; 21 (1): 142-145. doi: 10.1177 / 1524839919884912